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May DCE help tackle treatment non-adherence?

Low adherence to prescribed medical treatments is an ever present and complex problem, especially for patients with a chronic illness. Factors related to low adherence include psychiatric disorders, and treatment factors, such as the duration of the treatment, the number of medications prescribed, the cost, and the frequency of dosing. Non-adherence can put the patient at risk of unnecessary further health complications such as relapse or hospitalization, and it can also carry a significant economic burden.

One of the most commonly advocated ways to improve adherence is the improvement of the doctor-patient relationship; patient-physician partnerships are essential when choosing amongst various therapeutic options to maximize adherence. This relationship is crucial in chronic diseases.

While thinking of patient-centered care in terms of decision-making about individual options for treatment, discrete choice experiment (DCE) technique seems to be a useful tool to evaluate patients’ preferences, in this case between treatment requirements and individual needs.

DCE is a quantitative technique for eliciting individual preferences and has its theoretical basis in random utility theory (RUT). This approach has been used by companies (i.e. widely in transport economics) to investigate the relative importance of the characteristics of their products influencing consumers’ demand.

DCE was introduced to healthcare in the early 90s and is based on the assumption that goods/services can be described by their attributes, and the value of goods/services depends on the nature and level of these attributes. DCE purpose is to understand how individuals evaluate selected attributes of a programme, product or service by asking them to state their choice over different hypothetical alternatives.

This month we have found a very interesting paper in which DCE technique is used to assess patients’ preferences for treatment of psoriasis with biologicals treatments.

Psoriasis is a common chronic-inflammatory diseases of the skin and joints and more severe psoriasis was associated with lower levels of quality of life. Patients’ well-being is affected mostly by disease management rather than by the disease itself. Patients receive topical and phototherapy, escalating to traditional systemic medication and only refractory psoriasis are treated with biologicals. Patients with psoriasis receiving biologicals are on average very satisfied with their treatment whereas patients with other treatments report higher dissatisfaction and this contributes to high rates of non-adherence.

In paper’s experiment, biologicals (TNF antagonists etanercept, adalimumab and infliximab and the interleukin 12/23 antagonist ustekinumab) have attributes and attribute levels for outcome and for process. Attributes’ combinations create hypothetical treatment scenarios, close to reality, and patients had to choose their preferred option. The results show patients preferences about different outcomes (e.g. probability of adverse events) and processes (treatment location, frequency, duration and delivery method) so that physicians should identify preferences of each single patient during shared decision-making in order to optimize treatment satisfaction, adherence and outcome.

Finally, DCE provide useful insights regarding patients’ preferences which would be ‘ignored’ in clinical outcomes: a further step towards patient-centricity.

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